missed dose panic

Aug 16, 2012

dear doc:

Looking for a bit of advice. I am on Atripla, and have been extremely vigilant with taking the medication, and haven't missed a dose since starting the regimen about a year and a half ago. Currently, Viral load <10 and Tcell count at 485 at the time of my last labs in early July, and everything else seemed in order.

Earlier this week i was unexpectedly stuck out of town, and, missed a dose as i was not carrying any extra medication for the unplanned overnite. (Lesson learned here...) While distracted at dinner, mulling around possible consequences for my error, and obviously distraught about missing a dose, a friend suggested that i just take one of his complera instead, on the logic that 'two out of three' is better than none, in regards to missing the dosages of all three medications. I couln't come up with a reasonable answer as to if this 'emergency substitution' would be a solution to my stress, or if i should just miss the dose and worry the night away.

would there be any negative side effects for this one time swap, and/or would it be better to have missed the dose, and just taken the next dose the prior evening.

Response from Dr. McGowan

Sorry to hear about your distress. It is a very important issue. I am very glad you are so focused on strict adherence, it is the best way to maintain long-term suppression of HIV.
2 things are important in regards to your situation:
1) Your virus had been fully suppressed for over 1 year. So if you did miss a dose (as can happen if a person has surgery and can't take anything by mouth for a few days) there would be no time for the virus to break out. Based on data from old treatment inetrruption trials, it may take a week to 10 days for virus to become detectable after stopping meds entirely. So not to worry.
2) The components of your regimen have a fairly slow clearance rate from the body..so your weren't completely uncovered. There were studies of Atripla in which, after virus was suppressed, people took the "weekend off" and just took meds Mon-Fri...the combo still worked well. So there is some "forgiveness" in this regimen.
As far as substituting Complera..again no harm done. I would not recommend this as a blanket rule, but you did your homework and noted that 2/3 meds are the same. The third medicine (rilpivirine) must be dosed with food (whereas Atripla is on an empty stomach) and the efavirenz part of Atripla would cause an interaction that would lower the rilpivirine levels further..so only 2/3 meds helping (but the efavirenz was still in your blood..so it worked out fine).
It is not good to substitute other meds because there could be specifiic toxicities (such as hypersensitivity reactions to one drug - abacavir, for example) that would not have been screened for.

Hope this puts you at ease, soory I did not get the question till late.

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